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SystemSpecial Investigations

Fraud Referral Triage

Every fraud referral scored and explained in minutes, so investigators open the files that matter first.

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SystemA crew of agents runs a whole process; people decide.
5specialist agents
5kinds of input
Soonfilm in production
The problem

Why it matters

Referrals pour in from adjusters, rules and models; most are noise, the real rings wait in the same queue, and state fraud-reporting clocks keep running.

What it does

How the solution handles it

Agents read each referral and the claim behind it, match prior claims, map the people, vehicles and providers linked to it, score the red flags with cited reasons and draft a recommendation. The SIU manager assigns or closes every referral; each decision and its reasons stay on a permanent audit trail.

How it works

How a referral moves

Five agents read each referral, match claim history and linked parties, score the red flags and draft a recommendation; an SIU manager assigns or closes every one.

What comes in
Referrals in4 channels · adjusters, rules, models, tip lines
Agents at work
Referral readerclaim + red flags
Then
Claim history matcherprior claims, parties
Link analystpeople, cars, clinics
Then
Red-flag scorerevery reason cited
Then
Triage writerdraft recommendation
A person decides
SIU managerassigns or closes
What comes out
Ranked SIU queue
Assigned cases
Audit trail
In and out

What it reads, and what it hands back.

What goes in

  • Adjuster referral forms
  • Rules-engine and model alerts
  • Hotline and tip reports
  • Claim file, notes and photos
  • Prior-claim database matches

What comes out

  • Ranked, cited SIU queue
  • Triage note with red flags
  • Assign or close log with reasons
  • Regulator-ready referral record

Who uses it

SMSIU managerSISIU investigatorCAClaims adjusterCOCompliance officer
What it changes

The difference, in numbers.

Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.

target
15min
from referral to a scored, cited triage note
In the queue1–2 days
With agents≈ 15 min
target
100%
of referrals logged with cited reasons, ready for a regulator’s file review
every assign and close explained
estimated
2×
the investigations opened per SIU analyst, with the same team
TodayWith agents

“Target” = design goal, measured in the live solution · “Estimated” = our estimate · Reporting clocks: N.Y. Ins. Law §405 (30 days), Cal. Ins. Code §1872.4 (60 days) · agents = the live solution’s configuration

Built on the engine

5 specialist agents. One person decides.

Referral readerreferral and claim file, read together
Claim history matcherprior claims across lines and years
Link analystwho and what connects to whom
Red-flag scorerscores with a cited reason for each
Triage writeropen, refer back or close, drafted
SIU managerassigns or closes
Special Investigations

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Document Tampering

Every invoice, photo and receipt checked for edits and reuse before money moves, each finding marked on the page.

Investigation File

Every SIU case becomes one cited file — timeline, statements, findings — ready for counsel or the fraud bureau.

Provider Fraud Review

Every bill from a flagged provider read against its records and peers, so upcoding and phantom visits surface early.

Build this
for your team.

We’ll show Fraud Referral Triage running on your own documents.

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